Go2Dr™ Patient Appointment Request Form

User Information

Please fill the representative name and relationship to patient fields below

Other

Representative / family member name

Relationship to patient

Paragraph text

Patient Information

First name

Last name

Date of birth

Gender

MaleFemale

Language

This field is optional

Phone number for contact

Best time for you to call me

My preferred appointment time(s)

Address

City

Zip

Insurance and HMO authorization if required

Primary Care Provider (PCP)

Preferred provider name

Optional, leave this field empty for first available provider

Medical Information

Symptoms/Complaint

Hours for Thomas F. Bembynista, D.P.M.

Tuesday

--
AM Green Hills Office

-- Midday Independence Office

-- PM Overland Park Office

Wednesday

-- AM Overland Park Office

-- PM Green Hills Office

Thursday

-- AM Overland Park Office

-- PM Green Hills Office

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About the Go2Dr™ Patient Appointment Request Form

We created the Go2Dr™ Patient Appointment Request form to make it easy for patients to request appointments when it’s most convenient for them. Patients can request an appointment on safe, secure servers.

Why Use Go2Dr™?

It's free to request the appointment!

It allows you to request a medical consultation online at a time that's convenient for you, including evenings and weekends.

It's safe and secure.

What Happens After I Submit an Appointment Request?

The designated contact for the participating healthcare provider receives an email alert once a new request is submitted and signs on to a secure web portal to view the appointment request.